THE FLOATING SHOULDER
THE FLOATING SHOULDER
Peter Janssen, md
INTRODUCTION
The floating shoulder is a combined fracture of the clavicle and the neck of the scapula. The cause is
usually a trauma of the shoulder by a fall with a motorcycle, moped or bicycle. It is a serious injury
mainly by additional serious complicating injuries that are often overlooked. Treatment usually
consists of osteosynthesis of the clavicle fracture.
Clavicle fractures occur frequently, especially for cyclists. Five percent of all fractures in adults are
clavicle fractures. Of all fractures in the shoulder region, 35 percent is a clavicle fracture.
Fractures of the scapula, however, are rare. Only 5 percent of all shoulder fractures are fractured
scapulae. Virtually all professional cycling riders have at least once during their career, and more
often, a broken clavicle.
Although cyclists often fall on their shoulders a fracture of the scapula is extremely rare.
A fracture of the scapula may occur solitarily but combined with the clavicle fracture is a notorious
injury known under the name FLOATING SHOULDER.
Definition of floating shoulder: clavicle fracture with a fracture of the neck of the scapula, constitutes
about 0.1% of all fractures.
It is always a serious injury in which an extensive specialistic examination is necessary for the correct
diagnosis and determination of the severity of the additional injuries, before starting the treatment.
PITFALLS
The floating shoulder is always the result of a high energy trauma, often in combination with other
serious injuries that often are overlooked and therefore remain untreated.
Understanding of the pathological anatomy and right treatment is of great importance to the
sometimes significant morbidity of this injury.
POSSIBLE ADDITIONAL INJURIES OR PROBLEMS
• rib fractures
• Pneumothorax or hematothorax
• Severe head injury
• Bleeding subclavian artery
• Brachial plexus injury
• Cervical spine injury
• Blunt abdominal trauma (liver damage)
• Nerve scapularis injury
• Nerve axillaris injury
• Other fractures e.g. wrist and elbow.
• Adequate pain relief is needed. This trauma causes much pain.
Multidisciplinary research of the patient by various specialists is needed. The injury itself is a matter
of an orthopaedic surgeon. The entire patient has to be examined by specialists with special
knowledge and attention of the neurovascular system in this area. It is necessary to have a clear idea
of the severity of the injury and the extent of the additional injuries.
THE FLOATING SHOULDER
THE SUPERIOR SHOULDER SUSPENSORY COMPLEX (SSSC)
The upper arm is firmly connected to the body by a bony and ligamentous ring. This ring is called the
superior shoulder suspensory complex (SSSC) which ensures a stable connection of the arm with the
body.
This ring is formed by:
• the clavicle
• The acromioclavicular joint and associated ligaments. These are the coracoclavicular ligament
and the acromioclavicular ligament
• the acromion
• The coracoid process
• glenoid
A double break of this ring creates an unstable structure which causes a delayed and disturbed
healing and the risk of causing chronic complaints in the future.
A double-break of the SSSC must therefore be treated surgically by stabilizing of the ring or the
reconstruction of the SSSC.
A floating shoulder creates a so called 'dropping’ shoulder. A dropping shoulder has a significantly
lower position than the opposite healthy side. Since the function of the SSSC is lost, and thus the
stable connection between the upper arm and the body, it is impossible to elevate this arm actively.
This is an important alarm symptom.
Because of the weight of the arm, the fracture of the neck of the scapula is dislocated, so the risk of
persistent symptoms after consolidation of the fracture in this position is large.
Typically, a surgical intervention is necessary, where the clavicle fracture is fixed by means of a plate.
In medical terms this is called osteosynthesis of the clavicle.
This procedure is sufficient for the stability of the SSSC to recover and causing the scapula fracture to
be relieved and normally heals without causing complications.
The prognosis of the floating shoulder depends on the degree of dislocation (displacement) of the
fractures and the severity of the accompanying injuries of the soft tissues, in this case the brachial
plexus.
Healing of fractures lasts 6 -12 weeks. It can then take 6 - 9 months before mobility and strength
have recovered. A surgical intervention of the floating shoulder gives the best chance of a full
recovery. A small percentage of these patients, however, pain remains with a limited function of the
shoulder.
Photo 1
THE FLOATING SHOULDER
Photo 2
Photo 3
THE FLOATING SHOULDER
Photo 4
Photo 1: right shoulder view from the front.
Photo 2: photo of hematoma and dropping shoulder on 20 October 2012. 18 days after the accident.
Photo 3: fracture neck shoulderblade with dislocation and clavicle fracture with dislocation. The
floating shoulder.
Photo 4: Thet Superior Shoulder Suspensory Complex (SSSC)
Udon Thani, Thailand
December, 2012